• Feature

    Extending Adherence

    Adherence typically declines when an individual's episode of care ends. It needn't, if you can remove the roadblocks.

    Feature Adherence

    Patrice Hazan PT, DPT, MA, calls it "the revolving door of physical therapy."

    "Our patients successfully complete individual physical therapy. The episode of care ends with a home exercise program and recommendations for community resources to tap. But they don't properly adhere, and 6 months later they're back for more physical therapy," she recounts. "I've heard other PTs use the same term to describe this phenomenon."

    It's hard enough for physical therapists (PTs) to get patients to faithfully adhere to the plan of care while they're still receiving physical therapist services. To expect them to continue performing their exercises after their physical therapy treatment ends might seem to be a hope too wild, a bridge too far.

    Hazan, founder and chief executive officer of GroupHab in Simpsonville, South Carolina, claims that it's not—at least for 1 segment of former patients. Her facility offers an array of PT-designed and -supervised group-exercise classes to senior citizens and people with conditions such as cerebral palsy and Parkinson disease. It's quickly built a track record in her community as a feel-good, mutually supportive success—one that Hazan, a board-certified clinical specialist in geriatric physical therapy, believes is replicable with seniors and other patient populations nationwide.

    Under her model, participants essentially never leave a PT's care—meaning there's a continuum of care after or between specific episodes of treatment. That's the reasoning, too, behind another vehicle for long-term PT oversight of patients: the APTA-endorsed annual checkup by a PT, which encourages the concept of "across-the-lifespan" physical therapist care.

    "The annual checkup is a wonderful idea," says Margaret Plack, PT, DPT, EdD, echoing the enthusiasm of other PTs interviewed for this article. "But the challenge in our health care system," she adds, "is that there's not a current payment mechanism for that." Plack is a professor in the Department of Physical Therapy and Health Care Sciences at George Washington University in Washington, DC.

    Hazan similarly regrets that her clients must pay GroupHab's $100 monthly fee out of their own pockets.

    "Medicare would save so much money if it would adopt a model like ours," she says. "It would help individuals adhere to their exercise prescription and could identify minor health issues before they become major ones."

    More later on those strategies for tracking patients and clients after physical therapist care has ended. PTs interviewed by PT in Motion want it known that improved adherence following an episode of care isn't solely reliant on future interaction with a PT.

    To the contrary, they say, the future, in a real sense, is now.

    "The building blocks of posttreatment adherence are laid during the initial physical therapist treatment sessions," Plack states.

    The key, she and others say, is for PTs to listen closely to their patients and clients, determine their goals and what will motivate them to change their health behaviors, identify and address barriers to adherence, and help those individuals develop healthy habits that, ideally, will last a lifetime.

    There are a variety of academic-sounding terms for all of this—"motivational interviewing," "reflective listening," and "the transtheoretical model of behavior change" among them. What they all boil down to is this: "For patients to be adherent, in the short or long term, they must choose to do it. They must want to do it. And they need our support to get it done. It won't happen unless we get inside their head and address adherence from their perspective."

    That's the mission statement of sorts of Alecia Thiele, PT, DPT, MSEd, an associate professor of physical therapy and the academic coordinator of clinical education at Clarke University in Dubuque, Iowa. "If we do what it takes to understand where our patients are, where they want to go, and what most excites and concerns them," she says, "and if we can match our words and actions to all that, the results can be beautiful," she says.

    Steps to Success

    Plack co-presented a program titled "7 Steps to Optimize Patient Adherence" at APTA's PT 2012 annual conference. Those steps, she enumerated, are:

    1. Motivate the patient.
    2. Negotiate shared meaning.
    3. Facilitate behavior change.
    4. Optimize adherence.
    5. Identify barriers to adherence.
    6. Assess and adapt patient education materials for patients with low health literacy.
    7. Maintain change through behavior counseling.

    The key, she says, is "to continually ask effective questions to better understand your patients. Because if you don't fully understand their personal motivations and goals, their environment and community, and their supports and barriers," Plack warns, "you can design the best home exercise program in the world, but if it doesn't fit that patient, it's useless."

    Sample questions, she says, include these: "How important is it to you to enhance your skills or change your behavior?" "How confident are you that you can do the exercises?" "Who or what can support you in doing your exercises?" "What barriers might get in your way, and how might we preempt them?"

    The transtheoretical model comes into play at the "facilitate behavior change" step. It describes 6 stages of health behavior change, from "precontemplation" (no intention of behavior change for the foreseeable future), through action, all the way to "termination" (desired health behavior is instilled and automatic). What the model means in practical terms is that the PT determines where the patient is on the continuum to behavior change and matches his or her teaching strategy to that individual's current needs.

    "For example," Plack says, "if the patient is at the precontemplative stage, I might say, ‘Let's talk about why this particular behavior change is important—and the potential risks of inaction. And, let me help you understand the disease process a little better.' But if the patient is at the action stage and he says he wants to walk, for example, but he just can't seem to establish a routine, I might ask, ‘What's standing in your way, and how can we work together to get past that?"

    "Optimizing adherence" could involve everything from ensuring, by observation, that the home exercise program is being properly performed, to encouraging accountability by having individuals set reminders on their computers or smartphones, and/or asking them to keep an exercise log.

    Adapting patient education materials for individuals with low health literacy means ensuring that all instructions are clear and easily understandable to that particular patient. "Think about the amount of jargon PTs use. It's pretty easy to see our potential for confusing people," Plack notes.

    She gives this example.

    "Sometimes I'll describe the exercise to the patient, we'll do it together, and I'll say, ‘Let's put it in your own words so it'll be easier for you to remember.'" In this manner, and after further conversation with the patient, a home exercise instruction that Plack herself might have worded, "Sit to stand from a chair hands-free 3x/day 5x each session" becomes the following detailed and nuanced—but simply written—narrative:

    "I will start by sitting on a chair. Then I will stand up, sit down, and stand up again. I will keep going until I come to standing 5 times. I will try not to put my hands on the chair when I stand up. I also will try not to sit down completely. I will just let my bottom lightly touch the chair. I will do this after breakfast, after lunch, and after dinner."

    The last of the 7 steps to optimize adherence, "maintaining change through behavior counseling," means promoting accountability throughout the treatment sessions by asking whether patients have done their exercises and if issues have arisen. It might also entail followup after the sessions have ended. "That could translate to anything from, ‘Let's set a time for you to come in a month from now' to ‘Please check in with me via email,'" Plack says. "It's a way to reinforce the ongoing need for accountability."

    An Open Question

    Robyn McHugh, PT, DPT, co-presented "Motivational Interviewing Techniques Can Improve Patient Self-Management" at APTA's NEXT Conference & Exposition in 2014.

    "The goal of motivational interviewing is to help elicit behavior change by encouraging patients to explore and resolve ambivalence and uncertainty," she says. "It's about helping patients identify their own motivation to change, as opposed to our directing them toward our agenda."

    Major components of motivational interviewing include asking "open-ended" questions—"How did it go with your exercise?", for instance, rather than "Did you do your exercises?"—and "reflective" listening that "helps people feel truly heard."

    McHugh, a board-certified clinical specialist in orthopedic physical therapy, is a PT at Cincinnati Children's Hospital in Ohio and director of the orthopedic physical therapy residency program there. She gives an example of reflective listening in a scenario in which the patient has said she's been too busy to exercise.

    "Repeat the statement and give her an opportunity to elaborate," McHugh advises. "If you detect a level of frustration, say, ‘It sounds like you find it frustrating to be so busy.' Allow her to work through that in conversation, instead of just jumping in with the suggestion, ‘Maybe you could exercise at night.' This type of listening is ‘reflective' in that it's like holding a mirror up to the patient as he or she is talking. It lets patients hear their own words and better understand their meaning and implications."

    Motivational interviewing, McHugh says, "isn't paternalistic. It conveys, ‘We're a team, and we need to figure out how this is going to work best for you.' It says, ‘Exercise is important to your continued health. How can we make it easiest for you to do it?' The PT is the coach, not the manager. The health habits we can help foster just by listening better and following the patient's lead can long outlast our own interactions with that individual."

    Typing Skills

    For PTs to "meet patients where they are" and get their buy-in on behavior change, they also should be able to recognize personality types and appreciate generational differences.

    "Identifying a patient's personality type and knowing how to optimally motivate a person who has that temperament and learning style can go a long way toward improving adherence," says Brenda Boucher, PT, PhD, an associate professor in the Department of Physical Therapy at Texas State University. "During orientation, we introduce our DPT students to an instrument called True Colors that helps them better understand themselves and others—including the patients and clients they'll be serving—based on their dominant personality traits."

    In that 4-color system, which refines the Myers-Briggs Type Indicator, "green"-dominant personalities are independent thinkers who respond best to evidence. "Gold" personalities are pragmatic and prefer information to be presented in black-and-white terms. "Orange" personalities are action-oriented and thrive on variety and choices. "Blue" personalities are people-oriented and best motivated by how their behavior change might affect others in their lives as well as themselves. The system assumes color combinations within each individual and weights manifestations and implications accordingly.

    Whether or not PTs take the time to school themselves in a color-coded or another personality-based instrument, "Clinicians would do well, in general, to closely observe and listen to their patients, and to pick up cues about how to best motivate them to adhere to the exercise plan in the near and long terms," Boucher says.

    Alecia Thiele urges her PT colleagues to consider generational differences, as well, in promoting home exercise for maximum staying power. She is a credentialed trainer in "bridging generational gaps" through Minneapolis-based Bridgeworks.

    "Patient adherence is a very challenging concept, and considering the patient's generation is only 1 piece of the puzzle," Thiele acknowledges. "But it can be a very important piece."

    "For example," she says, "a young adult from the Millennial generation who is tech-savvy and values multimedia presentation might benefit from putting reminders in his or her smart device as to when to do exercises, and from storing, on that same device, video taken during physical therapy of exercise being done correctly. Whereas, a Silent Generation patient who is in his 80s might prefer a handout and pictures he can bring home. The PT also could provide information on that patient's home exercise program that his Baby Boom-generation son or daughter could reference online."

    The Endorphin Effect

    "I always tell students, ‘In a sense, you're all pharmacists—you just didn't know it,'" says Kirk Peck, PT, PhD, who chairs the Department of Physical Therapy at Creighton University in Omaha, Nebraska, and is an associate professor there. "I teach exercise physiology, so, when I make that observation and students look at me funny, I explain, ‘When people exercise, endorphins are released in their brain. It's a pharmacologic effect, but it's a natural one. In this case, we want to get people addicted to it, so that it becomes a psychological motivator."

    "I always try to get my patients on a cardiovascular program—whether it's walking, riding a bike, or swimming," Peck says. "Walking is my first choice, because it's the easiest and requires no equipment. Some patients fall in love with it and get a kind of euphoria from it. As a result, it sticks. They're still walking long after they came to see me."

    Peck has been volunteering every Friday for 16 years at a pro bono clinic for Native Americans that's run by the Ponca Tribe of Nebraska. What he has learned, he says, is that "you never, ever know what's going to motivate people to keep exercising." He always finds out, for instance, if his patients have a dog. Dogs need exercise, too, and Peck has discovered that individuals who might not walk a hundred yards on their own behalf will walk miles each week for their animal companion's well-being.

    He also has learned never to underestimate the power of ego. Peck loves telling the story of a former patient who was loath to exercise even after a near-death scare that had put him in a coma. "I had to convince him to try riding the stationary bike at his apartment complex for 2 minutes to start off," Kirk recounts. "He was very angry about his physical health, and any discussion about starting an exercise program was met with tension."

    On his first attempt, however, the 60-something man felt acutely embarrassed that he couldn't keep up with a 90-year-old woman on the bike beside him who was "cranking away." By the time physical therapy sessions ended, he'd upped his bike time to more than 20 minutes per session and had dropped 20 pounds.

    "My philosophy with this patient was that any exercise at all was better than none, and if I could get him hooked on small bouts of it early on, he might increase the volume over time and stick with it," Peck says. "I also was hoping he'd benefit from the uplifting psychological aspects so commonly associated with ongoing exercise—in other words, that endorphin effect. The seed that I planted was enriched, as it turned out, when that 90-year-old woman entered the picture. The rest, as they say, was history."

    Safety in Numbers

    "The population I'm targeting with GroupHab is people with complex medical needs—which describes the vast majority of senior citizens," says Patrice Hazan, who fulfilled a longtime dream when she opened the facility in January 2015. "A standard home exercise program is simply not sufficient to keep them well. They need a program that includes aerobics, strengthening, balance, and flexibility components. I had long felt," she says, "that if we PTs could properly channel our knowledge and creativity, we could come up with something attractive to this population that would meet their needs."

    As Hazan described it in an essay in PT in Motion in February (see sidebar below), "Every client gets a detailed physical therapy assessment from a PT. We identify client goals and provide disease-specific education. We then recommend appropriate classes based on each person's functional capabilities—with individualized instruction in precautions, modifications, and adaptations. Our wide range of classes is reflected in their names, such as StrengthHab, CoreHab, JointHab, and MoveHab."

    To participants, the classes are a fun way to sweat—while socializing and enjoying the psychological and physical benefits of exercise. To Hazan, the classes are "really just me, using the knowledge I have as a PT, to keep people well."

    The concept is fresh enough that Hazan's initial press releases sparked local media coverage that quickly got the word out. Her classes—generally numbering 5 to 10 people—began filling up, and client enthusiasm prompted referrals from physicians.

    "People tend to have money for what's most important to them," Hazan says. "Our classes offer music, camaraderie, and even a bit of healthy competition. People feel safe. They aren't worried about injury because they know we've assessed their abilities and are watching them closely. They often tell me they feel far more challenged—in a good way—than they did doing the same things over and over in a standard home exercise program."

    Hazan sees PT-led group exercise as a great model for other patient populations, as well.

    "For instance, so many patients—not just seniors—would benefit from group exercise designed to strengthen their back," she says. "Every physical therapy practice should have a back class for patients who recently ended their physical therapy sessions."

    Hopeful Trends

    Margaret Plack agrees that "the socialization piece is a great way to enhance adherence," and adds, "Our practice models would do well to move in that direction, because some people love the social aspect of group exercise. However," she continues, "all former patients would benefit from an occasional check-in with a physical therapist."

    That's why Plack believes having those patients come in for an annual checkup by a PT is a model that should be part of the profession's repertoire.

    Kirk Peck agrees. "The annual checkup is a mindset in the right direction," he says. "It's where we need to go. It's all about maintaining our relationship with patients and clients, and doing everything we can to ensure their continued wellness."

    Taking that step not only will enhance patient adherence after an episode of care, Plack says, but it also will bolster what she sees as an encouraging trend in physical therapy.

    "More and more physical therapy practices are providing patients and clients with strategies across the continuum, from health and wellness through disability and chronic disease," she notes. "Payment challenges remain, but more and more people are being afforded opportunities for more healthful living under a PT's watch. That's a positive thing."

    Eric Ries is the associate editor of PT in Motion.

    The Tech Connection

    Can the use of technology enhance adherence to a home exercise program in patients with multiple sclerosis?

    That was what an osteopathic medicine student at Holy Name Rehabilitation Center in Teaneck, New Jersey, sought to determine in a research study conducted over 3 months in early 2015. The answer was a resounding "yes," says Jason Kavountzis, PT, MPT, the center's director of rehabilitation services, who worked with the study's 8 offsite patients.

    "We're located just outside of New York City, but we get patients from southern New Jersey, Pennsylvania, and upstate New York," he notes. "It's difficult for some of these individuals to come to us for physical therapy, so, after we'd conducted baseline functional assessments of these 8 patients onsite at Holy Name, the study used iPads, Facetime, and Fitbit exercise trackers to create an easy at-home rehab program, which our osteopathic medicine student monitored remotely."

    Adherence was strong, and the participants did "unbelievably well" on their reassessed functional tests, Kavountzis reports. Patient comments afterward included "The iPad made it simple," "Supervision kept me motivated," "It really got me moving," and "The study helped me get more active and set goals."

    "One patient told me she hadn't been up to the third floor of her house in 3 years, but that she had made it up there by the end of the 12 weeks," Kavountzis says. "She was so happy that she cried."

    While he concedes that adherence "dropped off a little bit" once the study ended and the former participants no longer were being monitored by the Holy Name team, he believes technology has much to offer patients, regardless of presentation, both during and after physical therapist treatment. That's particularly important for people with multiple sclerosis, he notes, because "exercise is critical to retaining function throughout their lifespan."

    Whatever the condition or injury that brought them to the PT, "It can be valuable for people to have video you've taken of them in which they're doing their exercises correctly," Kavountzis says. "Also, I often urge patients to think about getting a Fitbit or another wearable technology that encourages accountability."

    That works well for him in his daily life, he adds. "Fitbit is simple. You can't mess it up. I just look down, and I can see, ‘I haven't reached my steps goal for today yet, so I'd better get going.'"

    Robyn McHugh, PT, DPT, is "very excited" by the array of wearable devices now available. "Not everyone can afford them—especially the pricier ones," she notes, "but, still, these technologies give patients and PTs more ways to make exercise enjoyable, and to objectively track adherence both during and after physical therapy."

    Margaret Plack, PT, DPT, EdD, is high, too, on wearables' potential to promote adherence after physical therapist treatment has ended—provided a PT remains in the picture.

    "Technology alone is not enough," she argues. "For many people, it's motivational at first, but then you go back to your bad habits. My Garmin tells me to move every couple of hours—and I ignore it," she confides with a laugh. "If I was scheduled to come in for an annual physical therapy checkup, though, and I knew that my PT would be checking my exercise numbers for the past few months on my Garmin Connect, I'm pretty sure I'd be more likely to do what the device was telling to me to do."

    Resources

    PT in Motion compiled this list in consultation with PTs interviewed for this article.

    Annual Checkup by a Physical Therapist

    • www.apta.org/AnnualCheckup/

    Health Literacy

    Motivational Interviewing

    Personality Assessment

    PT-Led Group Exercise

    Transtheoretical Model of Behavior Change


    Comments

    What does it mean to negotiate shared meaning?
    Posted by Cassandra Piette on 7/10/2018 6:23:56 PM

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